Essential

Revision Notes For MRCP

IN
Neurology

Gehad gamal, MRCP (UK), MD in cardiology

Ambassador of European association of cardiovascular imaging in
Egypt
Registered in Irish Medical Council (IMC)
Frontal lobes lesions

Expressive /Broca's/ non fleunt aphasia: For example, a

person may say something like, "Drive, store. Mom."
meaning to say, "My mom drove me to the store today
Disinhibition
Perserveration (frequent actions)
Primitive reflexs
Anosmia
Inability to generate a list
Parietal lobe lesions
Sensory inattention
Apraxia : the individual has difficulty with the motor
planning to perform tasks or movements when asked,
provided that the request or command is understood and
he/she is willing to perform the task
Astereognosis (tactile/somatosensory agnosia) , it is
connected to tactile sensethat is, touch. Patient finds it
difficult to recognize objects by touch based on its
texture, size and weight.
Inferior homonymous quadrantanopia
Gerstmann's syndrome (lesion of dominant parietal):
alexia, acalculia, finger agnosia and right-left
disorientation
Temporal lobe lesion
Wernicke's aphasia (Receptive aphasia, fluent aphasia,
or sensory aphasia) , is a type of aphasia in which an
individual is unable to understand language in its spoken
form. Even though they can speak using grammar, syntax,
rate, and intonation, they typically have difficulty
expressing themselves meaningfully through speech.
Superior homonymous quadrantanopia
Auditory agnosia: there is difficulty distinguishing
environmental and non-verbal auditory cues including
difficulty distinguishing speech from non-speech sounds
even though hearing is usually normal. (EXAMINER:
What did you eat for breakfast?...... PATIENT: Breakfast,
breakfast, it sounds familiar but it doesn't speak to me )
Occipital lobe lesions

Homonymous hemianopia
Cortical blindness
Visual agnosia
Neurological
examination
INSPECTION MOTOR SENSATION CEREBELLAR
POWER
A home visit is requested by the husband of a 71-year-old woman
who is 'off her legs'.
On arriving the patient states that since mid-morning her left arm
has felt weak and a degree of facial asymmetry is noted when she
smiles.
She is normally fit and well other than a past history of
hypertension for which she takes ramipril.
What is the most appropriate action?

A. Arrange same-day medical admission

B. Dial 999 for emergency admission
C. Arrange review at rapid access TIA clinic
D. Arrange review at rapid access TIA clinic + give aspirin 300
mg
E. Dial 999 for emergency admission + give aspirin 300 mg
 B. Dial 999 for emergency admission
This lady is most likely having a stroke, nowadays rightly
recognised as a medical emergency. Aspirin should only
be given once a haemorrhagic stroke has been excluded
 A patient with atrial fibrillation, hypertension and
hypercholesterolemia presents with sudden-onset right-
sided weakness, hemianopia and aphasia.
This occurred an hour previously while he was eating his
breakfast.
He is taking aspirin, simvastatin, ramipril and digoxin.
What action would you recommend?
CT within the next 4 hours, and transfer to an acute stroke
unit
Immediate CT with a view to iv thrombolysis
Immediate oral aspirin, then CT as soon as possible
Immediate CT with a view to heparinisation
Admission to a stroke unit, with CT in the next 24 hours
 B
Therapeutic nihilism is no longer acceptable for stroke
Intravenous thrombolysis (0.9 mg/kg iv rtPA (recombinant tissue
plasminogen activator) over 1 hour) is now licensed in the UK for
acute ischaemic stroke within 4.5 hours
Unfortunately, only a subset of patients presents within the time
window
Both evidence from randomised trials and a Cochrane meta-analysis
support this treatment
Acute stroke units are similarly supported by randomised trials, and
thrombolysis should occur in this setting, but answers A (CT within
the next 4 hours, and transfer to an acute stroke unit) and E
(Admission to a stroke unit, with CT in the next 24 hours) are not the
immediate concerns
Aspirin should be administered only after CT, and should be
avoided for 24 hours if the patient is thrombolysed
Heparin has never been shown in randomised trials to benefit
ischaemic stroke, or any ischaemic stroke subtype, in any setting
 Stroke: management
NICE also issued stroke guidelines in 2008, although they modified
their guidance with respect to antiplatelet therapy in 2010.
blood glucose, hydration, oxygen saturation and temperature
should be maintained within normal limits
blood pressure should not be lowered in the acute phase unless
there are complications e.g. Hypertensive encephalopathy
aspirin 300mg orally or rectally should be given as soon as
possible if a haemorrhagic stroke has been excluded
with regards to atrial fibrillation, the RCP state: 'anticoagulants
should not be started until brain imaging has excluded haemorrhage
if the cholesterol is > 3.5 mmol/l , start statin
Thrombolysis should only be given if:
It is administered within 4.5 hours of onset of stroke symptoms
haemorrhage has been definitively excluded (i.e. Imaging has
been performed)
Alteplase (TPA) is currently recommended by NICE.
 Absolute CI

- Previous intracranial haemorrhage

- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
 Relative CI

- Concurrent anticoagulation (INR >1.7)

- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in preceding 2 weeks
Ischemic Stroke Treatment

TPA, the Gold Standard,

tPA works by dissolving the clot and improving blood flow to the
part of the brain being deprived of blood flow. If administered
within 3 hours(and up to 4.5 hours in certain eligible patients), tPA
may improve the chances of recovering from a stroke.

Endovascular Procedures
Another treatment option is an endovascular procedure called
mechanical thrombectomy, strongly recommended.
To remove the brain clot, doctors thread a catheter through an
artery in the groin up to the blocked artery in the brain. The stent
opens and grabs the clot, allowing doctors to remove the stent
with the trapped clot. Special suction tubes may also be used.
The procedure should be done within six hours of acute stroke
symptoms, and only after a patient receives tPA.
Hemorrhagic Stroke Treatment

Endovascular Procedures
These procedures are less invasive than surgical treatments,
and involve the use of a catheter introduced through a major
artery in the leg or arm, then guided to the aneurysm or AVM;
it then deposits a mechanical agent, such as a coil, to prevent
rupture.

Surgical Treatment
For strokes caused by a bleed within the brain (hemorrhagic
stroke), or by an abnormal tangle of blood vessels (AVM),
surgical treatment may be done to stop the bleeding. If the
bleed is caused by a ruptured aneurysm (swelling of the vessel
that breaks), a metal clip may be placed surgically at the base
of the aneurysm to secure it.
 Secondary prevention

NICE also published a technology appraisal in 2010 on the use

of clopidogrel and dipyridamole
clopidogrel is now recommended by NICE ahead of
combination use of aspirin plus modified release (MR)
dipyridamole in people who have had an ischaemic stroke
aspirin plus MR dipyridamole is now recommended after an
ischaemic stroke only if clopidogrel is contraindicated or not
tolerated, but treatment is no longer limited to 2 years' duration
MR dipyridamole alone is recommended after an ischaemic
stroke only if aspirin or clopidogrel are contraindicated or not
tolerated, again with no limit on duration of treatment
With regards to carotid artery endarterectomy:

recommend if patient has suffered stroke or TIA in the

carotid territory and are not severely disabled

should only be considered if carotid stenosis 70- 99%

according ECST (European Carotid Surgery Trial lists)
criteria
or
> 50% according to NASCET (North American Symptomatic Carotid
Endarterectomy Trial)
A 71-year-old man is reviewed following an ischaemic
stroke. He is known to be intolerant of clopidogrel. What is
the most appropriate therapy to help reduce his chance
of having a further stroke?

A. Aspirin + dipyridamole, Stop dipyridamole after 2

years
B. Dipyridamole, Stop dipyridamole after 2 years
C. Aspirin lifelong
D. Warfarin
E. Aspirin + dipyridamole lifelong
 E. Aspirin + dipyridamole lifelong
Stroke management according NICE stroke guidelines in
2008, although they modified their guidance with respect
to antiplatelet therapy in 2010.
A 59-year-old man with no significant past medical history is
admitted to hospital following an ischaemic stroke. He presented
outside of the thrombolysis window and is treated with aspirin
for the first few days. His blood pressure is 130/80 mmHg,
fasting glucose is 5.6 mmol/l and fasting cholesterol is 3.9
mmol/l. He makes a good recovery and has regained nearly all of
his previous functions upon discharge. Following recent NICE
guidelines, which of the following medications should he be
taking upon discharge (i.e. after 14 days)?

A. Aspirin + statin
B. Aspirin + dipyridamole + statin + ramipril
C. Clopidogrel + statin
D. Aspirin + dipyridamole
E. Aspirin + dipyridamole + statin
 Clopidogrel + statin
If the cholesterol is > 3.5 mmol/l (135 md/dl )patients
should be commenced on a statin.
Many physicians will delay treatment until after at least
48 hours due to the risk of haemorrhagic transformation
Clopidogrel is now recommended by NICE ahead of
combination use of aspirin plus modified release (MR)
dipyridamole in people who have had an ischaemic stroke
A 19-year-old presents as she would like to start a combined
oral contraceptive pill. During the history she states that in
the past she has had migraine with aura. She asks why the
combined oral contraceptive pill is contraindicated. What is
the most appropriate response?

A. Theoretical risk of ischaemic stroke

B. Significantly increased risk of ischaemic stroke
C. Increased frequency of migraines
D. Migraine is an independent risk factor for venous
thromboembolism
E. Increased severity of migraines
 B. Significantly increased risk of ischaemic stroke
 Migraine during pregnancy paracetamol 1g is first-
line aspirin 300mg or ibuprofen 400mg can be used
second-line in the first and second trimester
Migraine and the combined oral contraceptive (OCP)
pill if patients have migraine with aura then the COC is
absolutely contraindicated due to an increased risk of
stroke (relative risk 8.72)
Migraine and menstruation many women find that
the frequency and severity of migraines increase around
the time of menstruation SIGN recommends that
women are treated with mefanamic acid or a combination
of aspirin, paracetamol and caffeine. Triptans are also
recommended in the acute situation
Migraine and hormone replacement therapy (HRT)
safe to prescribe HRT for patients with a history of
migraine but it may make migraines worse
 A 69-year-old patient with no previous medical history has been
diagnosed with a right-sided lacunar stroke.
You are now seeing him in the follow-up clinic at 6 weeks, and
his hemiplegia is improving. His total cholesterol is 5.5 mmol/l
and his blood pressure is 136/78 mmHg.
He is in sinus rhythm. His blood glucose level is normal.
He is treated with perindopril for hypertension and aspirin (which
he had already been taking prior to the recent stroke)
What secondary preventive regime should he be taking, on
the basis of current randomised evidence?
Aspirin, statin and diuretic
Aspirin and statin
Aspirin and beta blocker
Clopidogrel and statin
Aspirin
 D- clopidogril and statin
Trials have demonstrated the value of blood pressure
lowering, modification of blood fats and adequate
antiplatelet therapy in secondary prevention of stroke
Statins should be started independently of cholesterol
levels as they appear protective even when cholesterol
levels approach the average
Dual anti-platelet therapy with aspirin and dipyridamole
therapy for secondary stroke prevention was the treatment
of choice on the basis of the ESPS-2 trial, but this has
now been superceded by NICE guidance which
recommends clopidogrel
A 65-year-old woman presents with new, ongoing speech
disturbance. She is worried that she may have had a stroke.
Which one of the following scoring systems is it most
appropriate to use to evaluate whether she has had a
stroke?

A. CHADS2 score
B. ABCD2 score
C. RCP-RSE score
D. ROSIER score
E. CHADS2-VASC score
 D. ROSIER score
Stroke: assessment Whilst the diagnosis of stroke may
sometimes be obvious in many cases the presenting
symptoms may be vague and accurate assessment
difficult.
The FAST screening tool (Face/Arms/Speech/Time) is
widely known by the general public following a publicity
campaign. It has a positive predictive value of 78%.
A variant of FAST called the ROSIER score is useful for
medical professionals. It is validated tool recommended
by the Royal College of Physicians.
ROSIER score
 Exclude hypoglycemia first, then assess the following:

Loss of consciousness or syncope - 1 point

Seizure activity - 1 point

New, acute onset of:

- asymmetric facial weakness + 1 point
- asymmetric arm weakness + 1 point
- asymmetric leg weakness + 1 point
- speech disturbance +1 point
- visual field defect + 1 point
A stroke is likely if score > 0
Which one of the following statements regarding the
ROSIER score is correct?

A. It includes assessing the patients visual fields

B. A total score of 2 makes a diagnosis of stroke unlikely
C. Patients with a score > 4 are candidates for
thrombolysis
D. A history of seizure activity adds + 1 points to the
score
E. It can only be used for symptoms that have resolved
 A. It includes assessing the patients visual fields
A 72-year-old woman with a past history of treated hypertension
presents for review. Yesterday she had a 2 hour episode where
she couldn't find the right word when speaking. This has never
happened before and there were no associated features.
Neurological examination is unremarkable and blood pressure
was 150/100 mmHg. Her only current medication is amlodipine.
What is the most appropriate management?

A. Aspirin 300mg immediately + specialist review within 2

weeks
B. Specialist review within 2 weeks
C. Aspirin 300mg immediately + specialist review within 24
hours
D. Aspirin 75mg + outpatient CT brain
E. Specialist review within 24 hours
 C. Aspirin 300mg immediately + specialist review within
24 hours
This patient has had a transient ischaemic attack (TIA).
Her age, blood pressure and duration of symptoms put
her in a higher risk category.
Current guidelines advocate specialist review within 24
hours.
If a patient's symptoms have not fully resolved then
aspirin should be withheld until an haemohorragic stroke
has been excluded.
As this is a transient ischaemic attack (symptoms last less
than 24 hours) aspirin should be given as soon as
possible.
 Transient ischaemic attack
TIA

NICE issued updated guidelines relating to stroke and

transient ischaemic attack (TIA) in 2008.
They advocated the use of the ABCD2 prognostic score
for risk stratifying patients who've had a suspected TIA
 Criteria Points
A Age >= 60 years

B Blood pressure >= 140/90 mmHg

C Clinical features - Unilateral weakness

- Speech disturbance, no weakness

D Duration of symptoms - > 60 minutes

- 10-59 minutes

D Patient has DM
People who have had a suspected TIA who are at a higher risk
of stroke (that is, with an ABCD2 score of 4 or above) should
have:
aspirin (300 mg daily) started immediately specialist
assessment and investigation within 24 hours of onset of
symptoms measures for secondary prevention introduced as
soon as the diagnosis is confirmed, including discussion of
individual risk factors

If the ABCD2 risk score is 3 or below:

specialist assessment within 1 week of symptom onset,
including decision on brain imaging if vascular territory or
pathology is uncertain, refer for brain imaging
People with crescendo TIAs ???
 People with crescendo TIAs (two or more episodes in a
week) should be treated as being at high risk of stroke,
even though they may have an ABCD2 score of 3 or
below
 Antithrombotic therapy
clopidogrel is recommended first-line (as for patients
who've had a stroke)
aspirin + dipyridamole should be given to patients who
cannot tolerate clopidogrel
These recommendations follow the 2012 Royal
College of Physicians National clinical guidelines may
change following the CHANCE study (NEJM 2013),
giving high-risk TIA patients aspirin + clopidogrel for the
first 90 days compared to aspirin alone. 11.7% of aspirin
only patients had a stroke over 90 days compared to 8.2%
of dual antiplatelet patients
With regards to carotid artery endarterectomy:

recommend if patient has suffered stroke or TIA in the

carotid territory and are not severely disabled , should
only be considered if carotid stenosis > 50%
A 56-year-old man presents to the ER after developing trouble talking
after waking up this morning. The symptoms are consistent with
expressive dysphasia and lasted about 90 minutes before resolving
completely. Neurological examination is unremarkable. A diagnosis of
transient ischaemic attack (TIA) is made. His past medical history
includes ischaemic heart disease for which he is prescribed aspirin,
simvastatin and atenolol. Which one of the following factors is most
associated with an increased risk of going on to have a stroke?

A. History of ischaemic heart disease

B. History of aspirin use
C. Duration of this TIA
D. Expressive dysphasia during this TIA
E. His age
 C. Duration of this TIA
This TIA lasted greater than 60 minutes which scores 2 as
part of the ABCD2 prognostic scoring system.
It is therefore the most significant factor which would
increase his risk of going on to have a stroke.
 A 73-year-old man presents to his GP complaining of a headache
and blurring of vision in his right eye lasting for 5 minutes.
Two days later he developed sudden-onset, left-sided weakness
affecting both upper and lower limbs and lasting for 30 minutes.
His past medical history includes mild hypertension. He is a non-
smoker.
There are no neurological abnormalities. His blood pressure is
160/90 mmHg, heart rate 88 bpm. There are no audible carotid
bruits.
Which one of the following is the most likely diagnosis?
Migraine equivalent
Transient ischaemic attack secondary to carotid artery disease
Transient ischaemic attack secondary to cardioembolism
Transient ischaemic attack secondary to small-vessel disease
Transient ischaemic attack secondary to giant-cell arteritis
 B- Transient ischaemic attack secondary to carotid artery disease
The patient with headache, visual disturbance and weakness
The transient monocular visual disturbance is consistent with the description
of amaurosis fugax
Characteristically, patients describe a 'curtain coming down' over their vision,
but are just as likely to describe blurring or greying
Any suggestion that this disturbance is altitudinal (ie has a horizontal cut-off)
enhances the possibility that this is a vascular disturbance of the retinal vessels
The subsequent left-sided weakness is suggestive of aright cerebral
hemisphere transient ischaemic attack
The combination of these two strongly points towards a right internal carotid
artery stenosis as the source of platelet emboli, although other sources of emboli
should be considered
However, cardioembolism is unlikely in the absence of either atrial fibrillation
or previous cardiac symptoms (of either cardiac ischaemia or cardiac failure)
Transient occlusion of a small penetrating vessel could cause the hemiparesis,
but not the amaurosis fugax
Giant-cell arteritis should always be considered in patients over 60 years of
age, but there are no specific features to support the diagnosis, although it is
always worthwhile checking the ESR

Migraine equivalents (aura-like symptoms without headache) can provide

diagnostic difficulties
A 60-year-old man is referred to the rapid access TIA clinic
after experiencing a number of transient episodes of right-
sided weakness. Which one of the following factors is not
part of ABCD2 score used to estimate his risk of future
stroke?

A. Clinical features
B. History of diabetes mellitus
C. Blood pressure
D. History of aspirin use
E. Duration of symptoms
 D. History of aspirin use
NICE issued updated guidelines relating to stroke and
transient ischaemic attack (TIA) in 2008. They advocated
the use of the ABCD2 prognostic score for risk stratifying
patients who've had a suspected TIA:
A 63-year-old female is reviewed in the rapid access transient
ischaemic attack clinic. For the past three weeks she has been
having episodes of transient loss of vision in the right eye.
Carotid ultrasound reveals a 48% stenosis of her right carotid
artery and an ECG shows sinus rhythm. She was started on
aspirin 300mg od by her own GP after the first episode. What is
the most appropriate management of this patient?

A. Warfarin
B. Clopidogrel
C. Carotid endarterectomy
D. Aspirin
E. Aspirin and dipyridamole
B- Clopidogril

Antiplatelets
TIA: clopidogrel
ischaemic stroke: clopidogrel

Clopidogrel is recommended first-line (as for patients who've

had a stroke)
aspirin + dipyridamole should be given to patients who cannot
tolerate clopidogrel
With regards to carotid artery endarterectomy:
- recommend if patient has suffered stroke or TIA in the carotid
territory and are not severely disabled
- should only be considered if carotid stenosis > 50%
 A 51-year-old man underwent aortic valve replacement, which
was uncomplicated. Despite his history of alcohol abuse, he
was anticoagulated with warfarin.
After discharge it was noted that he had missed clinic
appointments.
Some 4 months later he was admitted to the Emergency
Department with a dense right hemiparesis and moderately
severe global dysphasia, unkempt and smelling of alcohol. His
INR was 1.4.
There was a soft diastolic murmur at the left sternal edge and
during his admission he developed a fever of 37.9 C.
Which one of the following is the most likely diagnosis?
Left-sided intracerebral haemorrhage
Thromboembolic stroke secondary to bacterial endocarditis
Left-sided subdural haematoma
Left, middle cerebral territory, infarction secondary to
cardioembolism
Left hemisphere lacunar stroke
 D- Left, middle cerebral territory, infarction secondary to
cardioembolism
The patient with hemiparesis and moderately severe global
aphasia
The history suggests a large lesion in the left, middle cerebral
artery territory involving the cortex
This rules out the possibility of a lacunar stroke, which is
always subcortical
This may have been the result of a cerebral haemorrhage as he
is on warfarin (although at subtherapeutic doses)
There is no suggestion of head trauma (although this does not
exclude it)
His symptoms are more likely to be the result of cerebral
infarction caused by cardiac embolism from the aortic valve
Bacterial endocarditis needs to be excluded, but fever after
stroke is more commonly the result of pneumonia or urinary
tract infection which can easily be screened for
 A 57-year-old man presents to the Emergency Department
complaining of a clumsy right hand and difficulty speaking.
His symptoms came on that morning, and were still present 8
hours later. His past medical history includes hypertension and
migraines as a young man. He smokes 10 cigarettes per day.
On examination he was found to have some weakness of the
intrinsic hand muscles on his right only.
Visual fields, speech and sensation were normal. Blood
pressure was 180/100 mmHg.
Which one of the following is the most likely diagnosis?
Migraine equivalent
Left pontine microhaemorrhage
Neck-tongue syndrome
Left, middle cerebral artery territory, cardioembolic stroke
Left hemisphere lacunar stroke
 E- Lacunar infarction
The patient with a clumsy hand and difficulty speaking
Lacunar infarcts are small deep infarcts with a maximum diameter of 1.5 cm and a
volume of 0.2-3.4 cm3
Lacunar infarcts mainly occur in the basal ganglia, lenticular nucleus and especially the
putamin, thalamus and white matter of the internal capsule, pons and centrum semiovale
The five classic lacunar syndromes are: pure motor hemiparesis, pure sensory stroke,
sensorimotor stroke, ataxic hemiparesis and clumsy-hand dysarthria
However in the modern imaging era many more syndromes have been described
The history given here is compatible with the dysarthria-clumsy hand syndrome, one of
the classic lacunar syndromes, ie subcortical stroke secondary to small-vessel disease
The usual site of damage in the dysarthria-clumsy hand syndrome is in the internal
capsule or pons
However, infarction is more common than a small haemorrhage
Both are caused by disease of small perforating arterioles
Risk factors include smoking, hypercholesterolemia and hypertension
Migraine equivalents (aura-like symptoms without headache) can provide diagnostic
difficulties and should always be considered in those with a previous history of migraine,
but there is no suggestion of the characteristic slow spread of symptoms in this patient
The neck-tongue syndrome consists of pain and paraesthesias in one half of the tongue
precipitated by neck movement
 A 69-year-old woman presents with a sudden onset of weakness of
her right arm and leg. She is known to be hypertensive.
There has been no headache, loss of consciousness, visual, speech or
sensory symptoms.
On examination, her blood pressure is 180/90 mmHg, pulse 100 and
regular. Heart sounds are normal. There is no carotid bruit. Higher
mental function tests are normal. There is no apraxia or neglect.
Speech, swallowing and sensation are all normal. There is no visual
field defect. There is a mild facial weakness sparing the forehead.
The right arm and leg are flaccid and weak. Reflexes and tone are
normal. There is a right extensor plantar response.
What is the most likely cause of this patients symptoms?
Cardioembolic stroke
Lacunar stroke
Right internal carotid artery atheroembolic stroke
Right internal carotid artery dissection
Right vertebral artery atheroembolic stroke
 Lacunar infarction
The patient with sudden onset of weakness of the right arm andleg
A sudden onset of focal symptoms and signs strongly suggests stroke
The presence of right-sided weakness involving the face, arm and leg, in
the absence of sensory loss, language disturbance, hemineglect or visual
field defect favours a small deep (lacunar) infarct affecting the
corticospinal tract at the level of either the internal capsule or the upper
pons
The sparing of the forehead, indicating upper motor-neurone facial
weakness, favours the former diagnosis
The term 'lacune' refers to a small deep infarct resulting from occlusion
of a penetrating branch
Infarcts occur predominantly in the basal ganglia, internal capsule,
thalamus and pons
Hypertension and diabetes are the main risk factors
Common lacunar strokes include a pure motor hemiparesis, pure
hemisensory loss, ataxic hemiparesis and
dysarthria clumsy-hand syndrome
 A 36-year-old man presents with a 1-day history of left-
sided neck pain and right-sided sensorimotor disturbance.
Shortly after the neck pain had begun, he had noted that
his left eyelid was 'drooping', and that he had developed
weakness and altered sensation in his right arm and leg.
He had recently visited a chiropractor for neck pain after
a road traffic collision. Examination reveals a left Horner
syndrome and weakness and sensory disturbance on the
right-hand side with an extensor right plantar.
What is the most likely clinical diagnosis?
Carotid artery dissection
Lateral medullary infarction
Posterior fossa space-occupying lesion
Subarachnoid haemorrhage
Venous sinus thrombosis
 A- The patient with Horner syndrome, weakness andsensory disturbance
following a visit to the chiropractor, (CAROTID ARTERY DISSECTION )
The constellation of symptoms and signs is best explained by a left carotid
artery dissection causing left hemispheric ischaemia, and subsequent right-
sided signs
Carotid and vertebral artery dissection are reported after chiropractic
manipulation and episodes of neck trauma, but are often spontaneous
The association of pain in the neck with an ischaemic stroke syndrome
should always raise dissection as a possibility
Carotid dissection commonly causes Horner syndrome because of the
intimate association of sympathetic nerve fibres and the carotid artery
There are no posterior circulation symptoms or signs to support a diagnosis
of lateral medullary infarction, though this does cause Horner syndrome
A posterior fossa lesion would present with progressive rather than sudden-
onset symptoms
A subarachnoid haemorrhage might present with sudden-onset symptoms, but
rarely with focal signs like these and not with Horner syndrome
Venous sinus thrombosis might cause right hemiplegia, but does not explain
the Horner syndrome and is not usually of sudden onset
 A 23-year-old homeless man is admitted with a history of becoming unwell
after sleeping rough for the last week.
A few days previously he had complained of feeling rather dizzy and slightly
nauseated. The following day he developed double vision and slurred speech.
His gait became unsteady and he was found collapsed by police officers. He is
brought to the Emergency Department. When asked, he complains of mild pain
situated in the back of his neck. He is drowsy and his speech is very slurred,
but comprehensible.
On examination of his eye movements, the left eye moves fully but the right eye
does not abduct. He has right-sided facial weakness with sparing of the brow.
In the limbs, he is mildly weak in the left arm and leg. The reflexes in all four
limbs are all very brisk and both plantar responses are extensor. Tests of co-
ordination are reasonably well performed on the bed, but when you get him out
of bed, his gait is very unsteady and he needs to be supported. His chest is
clear and he is apyrexial. The rest of the examination is normal.
What is the most likely diagnosis?
Vertebral artery dissection
Drug-induced cerebral arteritis
Wernicke's encephalopathy
Tuberculous meningitis
Right subdural haematoma
 A
On the face of it he appears to be obtunded, and any of these diagnoses will
cause that
A diagnosis of Wernicke's encephalopathy should be considered in any
patient with impaired conscious levels and abnormal eye movements
However, on closer appraisal of the history, he has a progressive brainstem
syndrome, confirmed on neurological examination, which demonstrated
impaired consciousness, dysarthria, sixth and seventh cranial nerve palsies,
bilateral upper motor neurone signs and ataxia
This is most likely caused by thrombosis of the vertebral artery after
spontaneous dissection (consider the neck pain) which has spread, or
embolised, up the basilar artery to occlude the brainstem perforating arteries
Tuberculous meningitis can also cause a basal meningitis, 'picking off
cranial nerves, but he is afebrile with no chest signs therefore making it less
likely, but still worth considering
There is no history of drug abuse, but cocaine can cause cerebral vasculitis
with multiple infarcts
 Brown Sequard Syndrome
 Brown Sequard Syndrome
As a result of the injury to these three main brain pathways the
patient will present with three lesions:

The corticospinal lesion produces spastic paralysis on the same

side of the body below the level of the lesion (due to loss of
moderation by the UMN).
At the level of the lesion, there will be flaccid paralysis of the
muscles supplied by the nerve of that level (since Lower motor
neurons are affected at the level of the lesion).
The lesion to fasciculus gracilis or fasciculus cuneatus results
in ipsilateral loss of vibration and proprioception (position
sense) as well as loss of all sensation of fine touch.
The loss of the spinothalamic tract leads to pain and
temperature sensation being lost from the contralateral side
beginning one or two segments below the lesion.
 A 62-year-old builder is admitted with a history of collapsing while lifting heavy
building blocks. In the Emergency Department he is unable to give a clear history, but
his wife says he was previously well. He has smoked all his life and regularly drinks
8-10 pints of beer on a Friday or Saturday night. On examination in the Emergency
Department, he was noted to be talking incomprehensibly and to have moderate
weakness of his right side.
On arrival on the ward 3 hours later, he appears awake but is no longer talking at all
and responds only to some, but not all, commands. His head and eyes look towards
the left. He moves his left arm and leg spontaneously, but even pinching the skin
elicits no movement of his right arm or leg. There is no obvious difference in the tone
or reflexes in his limbs, but the right plantar response is extensor.
On general physical examination, you note he is overweight and his blood pressure is
220/120 mmHg.
The remainder of your examination is normal. Apparently the result of CT head done
in the Emergency Department has not been written in his notes.
What is the most likely diagnosis?
Left hemisphere intracranial haemorrhage
Left internal carotid artery occlusion and cerebral infarction
Posterior fossa haemorrhage with rapid-onset hydrocephalus
Left hemisphere infarction with subsequent seizures
Continuing emboli from internal carotid artery stenosis
 A
This man has had some form of stroke followed rapidly by deterioration
The initial picture, however, is not one of posterior fossa damage
The possibility of showers of emboli causing such a picture is extremely
unlikely
He has clearly suffered from a left hemisphere stroke, and the
deterioration is in the same territory, not a different one
Seizures may cause temporary deterioration; however, in this case head
and eye turning are to the left, which suggests either a right frontal ictal
discharge or massive left frontal damage
In view of the limb features, the latter is more likely
The very rapid progression marginally favours haemorrhage as the
diagnosis, but cerebral infarction from left middle cerebral or internal
carotid artery occlusion causes a similar syndrome
Carotid dissection should also be borne in mind as a possible aetiology if
the strike is ischaemic rather than haemorrhagic
His risk factors include heavy alcohol intake and hypertension
 Extradural (epidural) haematoma

Bleeding into the space between the dura mater and the
skull.
Often results from acceleration-deceleration trauma or a
blow to the side of the head.
The majority of epidural haematomas occur in the temporal
region where skull fractures cause a rupture of the middle
meningeal artery.
Features
features of raised intracranial pressure
some patients may exhibit a lucid interval
A 73-year-old woman presents with episodic confusion and
headaches for the past week. She has a history of alcohol excess
and a background of atrial fibrillation and type 2 diabetes
mellitus. Her daughter reports that she has been having frequent
spells of confusion over the past few days. Last year she was
assessed for frequent falls. Her current medications include
bisoprolol, metformin and warfarin. Neurological examination is
unremarkable and her blood sugar is 6.7 mmol/l. What is the
most likely diagnosis?

A. Korsakoff's syndrome
B. Wernicke's encephalopathy
C. Extradural haematoma
D. Subarachnoid haemorrhage
E. Subdural haematoma
 E. Subdural haematoma
Fluctuating confusion/consciousness? - subdural
haematoma
This patient has a number of risk factors for a subdural
haematoma including old age, alcoholism and
anticoagulation.
Korsakoff's syndrome and Wernicke's encephalopathy do
not usually cause headaches (ataxia, unconciouse,
ophthalmoplegia)
 Subdural haematoma

Bleeding into the outermost meningeal layer.

Most commonly occur around the frontal and parietal
lobes.
Risk factors include old age, alcoholism and
anticoagulation.
Slower onset of symptoms than a epidural haematoma.
 -most commonly secondary to trauma e.g. old person / alcohol
-initial injury may be minor and is often forgotten
-caused by bleeding from damaged bridging veins between
cortex and venous sinuses
C/P
-headache -classically fluctuating conscious level (Fluctuating
consciousness = subdural haemorrhage) -raised ICP
 The combination of falls, alcohol excess, fluctuating
episodes of confusion and focal neurology points
towards a diagnosis of subdural haemorrhage.
The phrase 'fluctuating conscious level' is common in
questions and should always bring to mind subdural
haemorrhage
 A 69-year-old woman was taken to hospital with a sudden-onset, mild, right
hemiparesis and an inability to speak.
CT scan showed evidence of a recent left hemisphere infarction. She was found
to be in atrial fibrillation and was anticoagulated. While in hospital she had a
right-sided focal seizure and was treated with phenytoin. She made a good
recovery over the next 6 weeks and was discharged home. Phenytoin 300 mg at
night was continued, as was warfarin.
When she was seen in the follow-up clinic 3 months later atrial fibrillation was
still present and anticoagulation was continued, but the phenytoin was tailed off
to zero. Now, 2 months later, she has been re-admitted having developed a mild
right hemiparesis and drowsiness over the previous 10 days.
On further questioning her husband remembers that she tripped over the rug in
the lounge about 10 days earlier. Her INR is 5.1.
What is the most likely cause of her deterioration?
O Further cardioembolic stroke
O Concurrent lobar pneumonia
O Left hemisphere intracerebral haemorrhage
O Left subdural haematoma
O Recurrent seizures
 D
The patient with recurrent mild, right hemiparesis and AF
The initial story suggests that she suffered a cardioembolic
stroke secondary to atrial fibrillation, and that her symptoms
were the result of cortical infarction from a left middle cerebral
artery branch occlusion
However, her second admission with gradual onset of
symptoms over days is more likely to result from a subdural
haematoma secondary to excessive anticoagulation than a
recurrent stroke
Intercurrent infection could also cause deterioration, but not
specifically of the right hemiparesis, unless she had made a
less than complete recovery, in which case it might appear as
though the weakness had got worse
Recurrent seizures are uncommon, but could cause
deterioration if she was in partial status epilepticus
 Subarachnoid haemorrhage

Usually occurs spontaneously in the context of a ruptured

cerebral aneurysm but may be seen in association with other
injuries when a patient has sustained a traumatic brain
injury
Causes
-85% are due to rupture of berry aneurysms (conditions
associated with berry aneurysms include adult polycystic kidney
disease, Ehlers-Danlos syndrome and coarctation of the aorta)
-AV malformations
-trauma
-tumours

Investigations
- CT: negative in 5%
- LP: done after 12 hours (allowing time for xanthochromia to
develop)
Complications:

- Rebleeding (in 30%)

- Obstructive hydrocephalus (due to blood in ventricles)
- Vasospasm leading to cerebral ischaemia
 Management

Neurosurgical opinion: surgical intervention (clipping

and coils)
Nimodipine (e.g. 60mg / 4 hrly, if BP allows) has been
shown to reduce the severity of neurological deficits but
doesn't reduce rebleeding
Acute severe headache for DD:

1- Vascular (SAH)
2- Infection
3- Apoplexy
4- Trauma
Spastic paraparesis and
quadreparesis
A- With level

Cord compression: (trauma, tumour, ..)

Non cord compression (transverse myelitis e.g. HIV ,
MS, , osteoarthritis of the cervical spine)

Syringomyelia (dissociative loss)

Anterior spinal artery occlusion (dissociative loss)
B- Without level

Demyelination e.g. multiple sclerosis

Sub-acute combined degeneration
Friedrich Ataxia
Syphilis

Parasagittal meningioma
Tropical spastic paraparesis
Hereditary spastic paraplegia
Motor neuron disease
 A 23-year-old woman is sent to the Emergency Department
urgently. She is 36 weeks' pregnant. She describes the sudden
onset of right-sided numbness and dysphasia. She initially
developed tingling in the right side of her face that spread over
a matter of minutes to the right hand. Some 10 minutes later
she noticed she was having word-finding difficulty and that her
right arm felt clumsy. The whole attack resolved completely
within 20-30 minutes. By the time she arrived in the
Emergency Department her neurological examination was
normal. There is a previous history of headaches and vomiting
as a teenager, which varied according to her menstrual cycle.
Which of the following is the most likely diagnosis?
Spontaneous dissection of the right internal carotid artery
Transient ischaemic attack secondary to left hemisphere small-
vessel disease
Hemiplegic migraine
Partial epileptic seizure
Cerebral venous thrombosis
 C- migraine equivalent
The pregnant patient with right-sided numbness and dysphasia
The presence of a cortical sign such as dysphasia reduces the likelihood of
a lacunar transient ischaemic attack
Both carotid artery dissection (and consequent embolism to the left
middle cerebral artery) and cerebral venous thrombosis should be
considered
There is no history of the headache that is common with cerebral venous
thrombosis
However, the history of a slow march of symptoms and signs suggests
migraine aura without headache (migraine equivalent), not transient
ischaemic attack
Pregnancy is associated with an increased incidence of migraine and
stroke, especially from eclampsia and cerebral venous thrombosis in the
puerperium
Hemiplegic migraines are also more commonly seen in patients with a
previous history of migraine, which may have subsided years previously,
or in those with a positive family history of migraine